PARA HealthCare Analytics eJournal October 23, 2019 Grayscale Version

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O ctober 23, 2019 an HFRI Company

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NEWS FOR HEALTHCARE DECISION MAKERS Page 27

IN THIS ISSUE QUESTIONS & ANSWERS - PA Supervision - G0378 MUE Change - UHC 141 TOB - Modifiers GA, GX, GY and GZ

PAMA Private Payer Labs Payment Reporting

CARDIAC REPLACEMENT DEVICE CREDITS

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3 WAYS TO ACCELERATE YOUR FINANCIAL PERFORMANCE CALIFORNIA DOH LAB PAYMENT REPORTING REQUIREMENTS

The number of new or revised Med Learn articles released this week.

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The number of new or revised Transmittals released this week.

MODIFIER REQUIREMENTS FOR SERVICES FROM THERAPY ASSISTANTS 2020 CODING UPDATE DOCS AVAILABLE PAMA PRIVATE PAYER LAB PAYMENT RATE REPORTING ACCURATE CODING FOR VACCINES

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- Administration: Pages 1-51 - HIM /Coding Staff: Pages 1-51 - Providers: Pages 2,5,8,12,18,24,36 - Inpatient Observation: Page 5 - Laboratory: Pages 6,18,28 - Revenue Cycle: Pages 14,26

Taking Your Pricing And Revenue Cycle Management To The Next Level -

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PARA Weekly eJournal: October 23, 2019

PA SUPERVISION

Can you please elaborate on documentation requirements of the supervising physician for Physician Assistant's services in both a Critical Access Hospital (PA hospitalist) and Rural Health Clinic? Is co-signing by the supervising physician a condition of billing, or strictly a regulatory requirement by the state the PA is practicing in?

Answer: There are several layers of rules that may have inspired the co-signature requirement you have mentioned, but my guess is that it is imposed by hospital medical staff policies. Montana State regulations and Medicare regulations do not specifically require co-signatures on patient charts. That practice sounds like a conservative approach to ensuring that physician supervision is documented in order to manage the overall legal obligation of active supervision.

Medicare requires that a PA?s practice under the ?general? supervision of a physician. This means that the physician does not need to be in the room when care is rendered, but the physician takes an active role in supervising the PA. We did not find specific guidance in the Medicare manuals that explains exactly what documentation will satisfy as evidence of physician supervision, other than references to state law. The specific federal reference to physician supervision in the code of federal regulations is found at 42CFR ยง 410.74 - Physician assistants' services: https://www.law.cornell.edu/cfr/text/42/410.74

? (iv) Performs the services under the general supervision of a physician (The supervising physician need not be physically present when the physician assistant is performing the services unless required by State law; however, the supervising physician must be immediately available to the physician assistant for consultation.); The Medicare Benefit Policy Manual, Chapter 15 ? Covered Medical and Other Health Services, describes Medicare?s coverage of PA services at the following link: https://www.cms.gov/Regulations-and-Guidance/ Guidance/Manuals/downloads/bp102c15.pdf

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PA SUPERVISION

B. Covered Services Coverage is limited to the services a PA is legally authorized to perform in accordance with State law (or State regulatory mechanism provided by State law).

1. General The services of a PA may be covered under Part B, if all of the following requirements are met: - They are the type that are considered physician?s services if furnished by a doctor of medicine or osteopathy (MD/DO); - They are performed by a person who meets all the PA qualifications, - They are performed under the general supervision of an MD/DO; - The PA is legally authorized to perform the services in the state in which they are performed; and - They are not otherwise precluded from coverage because of one of the statutory exclusions.

The American Academy of PAs offers an interpretation of the ?Required Level of Supervision under Medicare? at this website: https://www.aapa.org/wp-content/uploads/2018/04/WEB18.066-Program-Director-Page-Redesign-Reimbursement-101-v2.pdf Required Level of Supervision under Medicare - Requires access to the collaborating physician by reliable electronic communication. ?? Personal presence of the physician is generally not required. ?? Medicare policies will not override state law guidelines or facility policies.

State Law: Here is the Montana state rule explaining the supervision requirements for PA?s: http://www.mtrules.org/gateway/ruleno.asp?RN =24%2E156%2E1622 24.156.1622 SUPERVISION OF PHYSICIAN ASSISTANT (1) A supervising physician may provide the following types of supervision to a physician assistant: (a) direct supervision; (b) onsite supervision; or (c) general supervision.

(2) The supervising physician shall consider the location, nature, and setting of the practice and the experience of the physician assistant when entering into a new supervision agreement and a duties and delegation agreement to assure the safety and quality of physician assistant services.

(3) The supervising physician shall meet face-to-face with each physician assistant supervised a minimum of once a month for the purposes of discussion, education, and training, to include but not be limited to practice issues and patient care.

(4) A supervising physician may supervise more than one physician assistant if the supervising physician: (a) agrees to supervise more than one physician assistant by signing and filing multiple supervision agreements with the board; 3

PARA Weekly eJournal: October 23, 2019

PA SUPERVISION

(b) provides appropriate and real time means of communication or back up supervision for the physician assistants; (c) determines the appropriate level supervision (direct, on-site, or general), based on the physician assistant's education, training, and experience; and (d) assumes professional and legal responsibility for all physician assistants under the supervising physician's supervision regardless of the varying types of supervision.

(5) The supervision agreement and duties and delegation agreement for nonroutine applicants must assure the safety and quality of physician assistant services, considering the location, nature, and setting of the practice and the experience of the physician assistant, and shall provide for: (a) an appropriate type or combination of types of supervision identified in (1), including specific supervising physician response and availability times; (b) an appropriate scope of delegation of practice authority and appropriate limitations upon the practice authority of the physician assistant; and (c) appropriate frequency and duration of face-to-face meetings.

(6) The supervision agreement and duties and delegation agreement for nonroutine applicants may provide for periodic changes in the type of supervision, scope of delegation, practice limitations, frequency, and duration of face-to-face meetings, and percentage of charts reviewed, based upon the duration and nature of experience gained by the physician assistant, the supervising physician's written assessment and evaluation of the physician assistant's experience and judgment, and other factors relevant to the nature and degree of supervision appropriate to assure the safety and quality of physician assistant services.

(7) The duties and delegation agreement must be submitted, if requested, to the board or its designee during the interview required pursuant to ARM 24.156.1601(3).

Modification of the Medicare Rules in 2020: one last point -- although the current regulations are, in Medicare?s opinion, flexible enough to allow for various models of PA practice under state law, many stakeholders asked CMS to clarify or further relax the physician supervision requirements.

Consequently, in the 2020 Medicare Physician Fee Schedule Propose Rule, CMS offer the following proposal: ?Specifically, we are proposing to revise § 410.74(a)(2) to provide that the statutory physician supervision requirement for PA services at section 1861(s)(2)(K)(i) of the Act would be met when a PA furnishes their services in accordance with state law and state scope of practice rules for PAs in the state in which the services are furnished, with medical direction and appropriate supervision as provided by state law in which the services are performed.

In the absence of state law governing physician supervision of PA services, the physician supervision required by Medicare for PA services would be evidenced by documentation in the medical record of the PA?s approach to working with physicians in furnishing their services. Consistent with current rules, such documentation would need to be available to CMS, upon request.

This proposed change would substantially align the regulation on physician supervision for PA services at § 410.74(a)(2) with our current regulations on physician collaboration for NP and CNS services at §§ 410.75(c)(3) and 410.76(c)(3). We continue to engage with key stakeholders on this issue and receive information on the expanded role of nonphysician practitioners as members of the medical team.

As we are informed about transitions in state law and state scope of practice governing physician supervision, as well as changes in the way that PAs practice, we acknowledge the state?s role and autonomy to establish, uphold, and enforce their state laws and PA scope of practice requirements to ensure that an appropriate level of physician oversight occurs when PAs furnish their professional services to Medicare Part B patients.

Our policy proposal on this issue largely defers to state law and state scope of practice and enables states the flexibility to develop requirements for PA services that are unique and appropriate for their respective state, allowing the states to be accountable for the safety and quality of health care services that PAs furnish."

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PARA Weekly eJournal: October 23, 2019

G0378 MUE CHANGE

Among the CMS NCCI MUE edit changes effective for DOS on and after 10/1/19, the facility MUE for HCPCS code G0378 (Hospital observation service, per hour) was deleted (MUE was previously 72). Could you provide any insight into the CMS rationale for which the MUE for G0378 was deleted? Thank you.

Answer: There is no published resource, as far as we can tell, that explains changes in MUE policy outside the annual NCCI Edit Manual publication ? which won?t be published for another month or so, and does not always explain a change in policy. The change in the MUE for G0378, as you have observed, happened between Q2 (when the MUE was 72 units) and Q3, when the MUE was discontinued for that code altogether.

Earlier this year, CMS changed its subcontractor for CCI and MUE edits; the new contractor, Capitol Bridge LLC, is shaking loose a few long-standing policies, and we expect more in the future. https://www.cms.gov/medicare/coding/nationalcorrectcodinited/index.html

The MUE edit for hourly observation care, G0378, has long frustrated billing staff at facilities because G0378 is not a payable HCPCS under OPPS. If the hospital exceeded the MUE, human intervention was often required to resolve the excess units on the claim (i.e. reporting the excess units on a second line under revenue code 0762 without a HCPCS) ? for a code that never carries reimbursement. In general, an MUE limit on a status N code, for which payment is always packaged on another line of the claim, is unrewarding for both Medicare and providers. It stands to reason that the new contractor saw little advantage in this edit, and discontinued it. This isn?t the first change that Capitol Bridge has effected this year.

Effective July 1, 2019, a modifier (59, XU, XE, XP, or XS) may be appended (if appropriate) to either the column 1 or the column 2 code to resolve a Procedure-To-Procedure (PTP) CCI edit.

Attached is PARA's paper describing this change in longstanding CCI policy.

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PARA Weekly eJournal: October 23, 2019

UHC 141 TOB

We've identified that approximately 70% of our non-patient labs are coming from our own clinics. Are we allowed to bill these on a CAH 85X bill type, as regular labs, since they were seen face to face, and blood was drawn at our clinics, although not at the hospital location?

Answer: If the person drawing the blood is a CAH hospital employee, or the clinic at which the blood was drawn is a provider-based clinic, then a CAH can report the lab service on an 851 claim type, which will be paid by Medicare on the cost-based reimbursement method rather than the Medicare ClinLab fee schedule. Incidentally, lab services billed on the 85x bill type are also exempt from the onerous commercial payment rate reporting requirements under the PAMA rules, which apply to only 14x type of bill hospital claims.

Here are links and excerpts from Medicare manuals that address your question: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c06.pdf

70.5 - Laboratory Services Furnished to Nonhospital Patients by Hospital Laboratory (Rev. 82; Issued: 02-08-08; Effective: 01-01-08; Implementation: 03-10-08) A nonhospital patient is an individual who is neither an inpatient nor outpatient of the hospital furnishing the service. (See the Medicare Benefit Policy Manual, Pub. 100-02, Chapter 1, ?Inpatient Hospital Services,? section 10, for the definition of a hospital inpatient and section 20.1 for the definition of a hospital outpatient). Nonhospital patients primarily are individuals from whom a specimen had been taken and sent to the hospital for analysis and the patient does not receive hospital outpatient services on the same day. For all hospitals except CAHs and Maryland waiver hospitals, if a beneficiary receives hospital outpatient services on the same day as a specimen collection and laboratory test, then the patient is considered to be a registered hospital outpatient and cannot be considered to be a non-patient on that day for purposes of the specimen collection and laboratory test. However if the non-CAH or Maryland waiver hospital only collects or draws a specimen from the beneficiary and the beneficiary does not also receive hospital outpatient services on that day, the hospital may choose to register the beneficiary as an outpatient for the specimen collection or bill for these services as non- patient on the 14X bill type.

For CAHs, payment for clinical diagnostic laboratory tests is made at 101 percent of reasonable cost, only if the individuals are outpatients of the CAH, as defined in 42 CFR 410.2, and are physically present in the CAH at the time the specimens are collected. Clinical diagnostic laboratory tests performed for persons who are not physically present (non-patients) at the CAH when the specimens are collected are made in accordance with the provisions of sections 1833(a)(1)(D) and 1833(a)(2)(D) of the Social Security Act. See also 42 CFR 413.70(b)(iii). Similarly, for Maryland waiver hospitals, the waiver is limited to services to inpatients and registered outpatients as defined in 42 CFR 410.2.

Therefore payment for non-patients (specimen only, TOB 14X) who are not registered outpatients at the time of specimen collection will be made on the clinical diagnostic laboratory fee schedule. Such services are covered to the extent appropriate.

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PARA Weekly eJournal: October 23, 2019

UHC 141 TOB

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c16.pdf

30.3 - Method of Payment for Clinical Laboratory Tests - Place of Service Variation (Rev. 3685, Issued: 12-22-16, Effective: 01-01-17, Implementation: 01-03-17) Non-Patient (Referred) Laboratory Specimen- A non-patient is defined as a beneficiary that is neither an inpatient nor an outpatient of a hospital, but that has a specimen that is submitted for analysis to a hospital and the beneficiary is not physically present at the hospital. All hospitals (including Maryland waiver hospitals and CAHs) bill non-patient lab tests on TOB 14X. They are paid under the clinical laboratory fee schedule at the lesser of the actual charge, the fee schedule amount, or the NLA (including CAH and MD Waiver hospitals). Part B deductible and coinsurance do not apply. ?

40.3 - Hospital Billing Under Part B (Rev. 3014, Issued: 08-06-14, Effective: ICD- 10: Upon Implementation of ICD-10 ASC-X12: 01-01-12, Implementation: ICD-10: Upon Implementation of ICD-10 ASC X12: 09-08-14) Hospital laboratories, billing for either outpatient or non-patient claims, bill the A/B MAC (A).

Neither deductible nor coinsurance applies to laboratory tests paid under the fee schedule.

Hospitals must follow requirements for submission of the ASC X12 837 institutional claim or the hardcopy Form CMS-1450. (See Chapter 25 for a description of the data set, and for requirements for the paper form. See the ASC X12 837 implementation guide for billing requirements for the electronic claim,).

When the hospital obtains laboratory tests for outpatients under arrangements with clinical laboratories or other hospital laboratories, only the hospital can bill for the arranged services. As discussed in section 30.3 (?Place of Service Variation, Critical Access Hospitals?) of this chapter, when the CAH bills a 14X bill type as a non-patient laboratory specimen, it is paid on the clinical laboratory fee schedule. For CAHs, payment for clinical diagnostic laboratory tests is made at 101 percent of reasonable cost only if the beneficiary is an outpatient of the CAH (85X TOB), as defined in 42 CFR 410.2, and is physically present in the CAH at the time the specimen is collected, for dates of service prior to July 1, 2009. However, for dates of service on or after July 1, 2009, the beneficiary does not have to be physically present in the CAH at the time the specimen is collected as long as certain criteria are met, per Section 148 of the MIPPA (i.e. other outpatient services are received by the beneficiary in the CAH on the same day the specimen is collected, or the specimen is collected by an employee of the CAH or of a facility provider-based to the CAH) (see Section 30.3 above, Critical Access Hospital).

Clinical diagnostic laboratory tests performed for a beneficiary who is not physically present at the CAH when the specimen is collected, by a non-CAH employee or who are not receiving other outpatient services in the CAH on the same day the specimen is collected, are paid are paid for under the clinical lab fee schedule. Similarly, for Maryland waiver hospitals, the waiver is limited to services to inpatients and registered outpatients as defined in 42 CFR 410.2. Therefore payment for non-patients (specimen only, TOB 14X) who are not registered outpatients at the time of specimen collection will be made on the clinical diagnostic laboratory fee schedule.

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PARA Weekly eJournal: October 23, 2019

MODIFIERS GA, GX GY AND GZ

Can you please tell me if GA GX GY or GZ is used on a service but another modifier, ex., Q8 is used, in which order should these be listed. We want to make sure we are putting the modifier in the correct order.

Answer: Commonly G modifiers are associated with services that are going to be denied by Medicare, however, the use of a G modifier does not always result in an automatic denial. Edits in the CMS claims file really only currently require CMS contractors to automatically deny claims with GZ modifiers. Modifiers GA, GY, and GZ should be reported in the first reporting modifier position on the claim. Modifiers GA, GY and GZ cannot be reported with modifier KX. Modifier GX was deleted from the HCPCS book in CY2002 and replaced with modifiers GA, GY and GZ. Definitions:

GA modifier description: When this modifier is reported it is used for an item or a service that is expected to be denied as not reasonable and necessary and to indicate an ABN was given to the beneficiary. These are also known as medical necessity denials.

The GA modifier can be reported on assigned and non-assigned claims for DMEPOS when one of the following Part B technical denials apply: - Prohibited telephone solicitation - No supplier numbers - Failure to obtain an advance determination of coverage When to use the GA modifier? The GA modifier should be used when there is reason to think a service will be denied because it does not meet the Medicare program standards for medically necessary care and the beneficiary was issued an Advanced Beneficiary Notice of Noncoverage (ABN). Use of the GA modifier is required any time a signed ABN is obtained or a patient?s refusal to sign an ABN has been witnessed properly in an assigned claim scenario (except an assigned claim for one of the specific DMEPOS technical denials as described above).

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PARA Weekly eJournal: October 23, 2019

MODIFIERS GA, GX GY AND GZ

The GA modifier should be reported on an assigned claim if the patient was given an ABN but refused to sign it and the services were provided.

An example if the procedure or service may not be covered by Medicare because the condition or diagnosis based on the Medicare Local Carrier (LCD) is not covered, it would be appropriate in this scenario to have the patient sign the ABN prior to the service being rendered to indicate the service is likely to be denied based on medical necessity in accordance, with the Medicare LCD. What happens to the claim if the GA modifier is reported?

In CY 2011 the GA modifier?s description was redefined to read ?Waiver of Liability Statement Issued as Required by Payer Policy?, and should be used to report when a required ABN is issued for a specific service. When the GA modifier is reported, CMS will automatically deny the claim line, for both UB04 and CMS1500 claim forms, and assign liability to the Medicare Beneficiary. The reason code 50 will appear on the claim payment remittance indicating the service(s) were denied due to not meeting medical necessity criteria.

What happens to the claim if the GA modifier is not reported?

The claim will be reviewed by Medicare, as is the process for any other claim, and it may or may not be denied, depending on the review results.

If the claim/procedure is denied, the beneficiary will not be held liable, but the provider will. Medicare will not pay the provider, nor is the provider allowed to collect from the beneficiary. The provider does have the option to appeal Medicare?s action limiting the beneficiary?s liability. The question of an abusive billing pattern could arise. If the patient has signed an ABN, it is possible that fraud and abuse implications may arise out of the omission of that fact under these circumstances, especially if there appears to be a consistent pattern of such omissions (i.e.; a pattern of failure to include the GA modifier when it is applicable). Also, if the claim is denied and an ABN is on file, the provider must go through the normal Medicare appeal channels, so caution should be used as the appeal process holds up resolution of the claim.

GY modifier description: Describes an item or service statutorily excluded or does not meet the definition of any Medicare benefit, refers to the statutory exclusions or categorical exclusions and the technical denials. ABNs are not an issue for these services. There are no ABN requirements for statutory exclusions. There are no ABN requirements for technical denials (except three types of DMEPOS denials previously mentioned in this article).

When should a provider report the GY modifier?

The GY modifier should be reported under the following case scenarios outlined below: - When the provider thinks a claim will be denied because it is not a Medicare benefit or because Medicare law specifically excludes it, or - When the provider thinks a claim will be denied because the service does not meet all requirements of the definition of a benefit in Medicare law, or - When the provider submits a claim to obtain Medicare denial for secondary payer purposes

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PARA Weekly eJournal: October 23, 2019

MODIFIERS GA, GX GY AND GZ

Examples of correct provider reporting of the GY modifier would be: - Routine physicals - Laboratory testing in the absence of signs or symptoms - Hearing aids - Air conditioners - Services rendered in a foreign country - Services rendered to a family member - Surgery performed by a physician not legally authorized to perform surgery in the state What happens to the claim if the GY modifier is reported?

The claim will be denied by Medicare. The carrier may auto-deny claims on edit when the GY modifier is reported. The Medicare beneficiary will be liable for all charges, whether personally or through other insurance. If Medicare processes the claim for payment, the GY modifier is irrelevant.

What happens to the claim if the GY modifier is not used?

The claim will be reviewed by Medicare and more than likely be denied. This action may take longer than if the GY modifier was reported due to the review process by Medicare. If the claim is denied as an excluded service or for failure to meet the definition of a Medicare benefit, the beneficiary will be liable for all charges, whether personally or through other insurance.

GZ modifier description: describes an item or a service that is expected to be denied as not reasonable and necessary and an ABN was not signed by the beneficiary. These are considered to be medical necessity denials. The GZ modifier is applicable to be reported on assigned and non-assigned claims for DMEPOS when on of the following Part B technical denials may apply: - Prohibited telephone solicitation - No supplier numbers - Failure to obtain an advance determination of coverage When does a provider report the GZ modifier?

The GZ modifier is used when there is reason for the provider to think a service will be denied because the service does not meet Medicare program standards for medically necessary care and the provider did not obtain a signed ABN from the beneficiary. If the provider presented an ABN and the Medicare beneficiary refused to sign and the provider rendered the services, the GZ modifier should be used on unassigned claims for all physician services and DMEPOS and also on assigned claims for which one of the DMEPOS technical denials is expected.

The following outline examples of when to report the GZ modifier: - 1. When a patient could not be given an ABN because of an emergency care situation, eg, in an EMTALA-covered situation in an emergency department or in an ambulance transport - 2. When a patient was not personally present at the provider?s premises and could not be reached to sign an ABN in a timely manner, eg, before a specimen is tested - When the provider realizes after the services have been rendered, an ABN should have been given for signature 10

PARA Weekly eJournal: October 23, 2019

MODIFIERS GA, GX GY AND GZ

What happens to a claim when the GZ modifier is used?

If the provider believes the item or service provided is expected to be denied and may not be reasonable or necessary, and an ABN is not signed, modifier GZ is reported. In this scenario, even through the beneficiary is not liable, if the provider is also found not liable for an unassigned claim or an assigned claim denied for a specified DMEPOS technical denial reason, the provider may be allowed to collect from the beneficiary.

What happens to a claim when the GZ modifier is not used?

It is not required to use the GZ modifier when Medicare is expected to pay, however, the claim will be reviewed by Medicare and like all of claims reviewed by Medicare, the claim may or may not be denied.

It should be noted however, the GZ modifier provided for physicians and suppliers wanting to submit a claim to Medicare who know that an ABN should have been signed but was not, and who do not want to risk of an allegation of fraud or abuse for claiming services that are not medically necessary. In reporting the GZ modifier on the claim, the provider is notifying Medicare that the services are not a covered benefit, therefore, the provider is reducing any risk of a mistaken allegation of fraud or abuse.

Example: A Medicare patient visited her internist for an annual examination. The physician performed and documented a comprehensive history and examination and counseled the patient on diet, exercise, and maintaining a healthy lifestyle. In addition to the examination, ordered laboratory testing. The patient indicated it was time for a Papanicolaou smear and pelvic and breast examinations, which had been performed a year ago. The physician failed to obtain a signed ABN and realized after the patient left that both of the services were unlikely to be covered.

The physician advised the patient the service is only covered by Medicare every 2 years. The physician did not perform all the screenings required for a Medicare Annual Preventive visit examination (G0439) however, the patient insisted the physician file a claim because she had supplemental insurance that would reimburse for the preventive visit as well as other preventative services rendered.

In this example, the rationale for using modifier GZ, the preventive medicine visit, Papanicolaou smear, and pelvic and breast examinations would not likely be covered because the of the frequency requirements established under Medicare benefit guidelines.

The preventive medicine examination is only covered when the appropriate screenings are performed in the same visit. In this case scenario, the depression and cognitive impairment screenings are part of the screening elements and were not performed, therefore the service is not covered.

Further, in the example, the physician failed to obtain a signed ABN, therefore the physician cannot hold the beneficiary financially liable. In this example, the modifier GZ is indicating to Medicare, the provider failed to properly notify the beneficiary of possible financial liability.

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PARA Weekly eJournal: October 23, 2019

CARDIAC REPLACEMENT DEVICE CREDITS

2018 Office of Inspector General (OIG) report identified payments reviewed for cardiac medical devices that had been recalled, and did not comply with billing requirements for reporting manufacturer credits. The report identified that Medicare incorrectly paid hospitals overpayments of approximately $4.4 million.

Overpayments were incurred because manufacturers issued reportable credits to hospitals for cardiac medical devices that had been recalled, but hospitals did not adjust their claims with proper condition codes, value codes and modifiers as required to reduce payment.

Federal regulations direct hospitals to report the replacement of implanted cardiac devices. If a hospital receives full or partial credit from a manufacturer for covered devices that are under warranty, or a device is replaced because of a recall or defect, these must be identified, and the claims billed for replacement devices should be tracked.

Medicare reduces payments for cardiac replacement devices when they are provided at no cost, a reduced cost or with a credit that is 50 percent or greater than the cost of the device. CMS requires the use of modifiers FB and FC to report implanted cardiac devices.

These modifiers are also required when reporting devices that are part of a recall. Modifier FB should be appended when a facility incurs no cost or receives full credit for the cost of a device and modifier FC should be appended when a facility receives manufacturer credit of 50% or more of the total cost of the device.

If a facility is not aware at the time of the device replacement procedure whether the device was provided at no cost, a reduced cost or with a 50 percent or greater credit, hospitals have the option of submitting a claim without the appropriate modifier and subsequently submitting a claim adjustment with the modifier once the determination of how the replacement device was obtained has been made or, they can hold the claim until the determination has been made.

THE

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PARA Weekly eJournal: October 23, 2019

CARDIAC REPLACEMENT DEVICE CREDITS

In addition to the modifier requirements for the replacement of implanted cardiac devices, CMS has issued a billing fact sheet to assist hospitals in properly reporting manufacturer credits to avoid overpayment recoveries with the appropriate condition codes and value codes.

https://www.cms.gov/Outreach-and-Education/ Medicare-Learning-Network-MLN/MLNProducts /Downloads/cardiacdevicecredits-ICN909368.pdf

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WAYS TO ACCELERATE YOUR FINANCIAL PERFORMANCE

TAKE YOURPRICING AND REVENUE CYCLE MANAGEMENT TO THE NEXT LEVEL

Business models in healthcare are evolving rapidly. Gone are the days when hospital pricing strategies were isolated from competitive pressure and facilities could flourish with less-than-optimal revenue cycle policies and procedures. To succeed today, hospitals must invest in new capabilities that can help them achieve previously unobtainable levels of precision, functionality and transparency across their pricing and revenue cycle domains.

The forces driving these changes are extensive and unrelenting. The rapid growth of high deductible insurance plans means consumers need, and expect, detailed price transparency to better shop procedures. As a result, direct price competition between providers is increasing. At the same time, the federal government is moving toward the imposition of its own price transparency requirements.

Reduced public and private payer reimbursements, meanwhile -- coupled with rising costs and more complex regulations ? make it essential for hospitals to ensure their revenue cycle is consistently performing at peak level. Importantly, that means developing the capacity to resolve denials quickly and effectively and identifying root causes to mitigate denials in the first place.

END-TO-END FINANCIAL OPTIMIZATION HFRI, which recently acquired PARA HealthCare Analytics, understands the convergence of forces at work in today?s market and the tools providers must possess to respond effectively. That?s why we?ve assembled a sophisticated array of services and technologies that collectively deliver the capabilities your hospital needs to flourish in the current marketplace.

From optimized pricing through peer analysis to comprehensive revenue cycle performance audits and technology-driven denial management and recovery, HFRI?s services ? whether accessed ala carte or as a single solution ? give you the ability to perfect pricing strategies while ensuring the highest level of revenue cycle performance. By allowing us to help you fine-tune your mission-critical financial processes, your facility will move forward with the confidence that comes from knowing you?ve left nothing to chance.

RATIONAL PRICING For hospitals and health systems, a solid financial footing begins with the development of a comprehensive, market-based pricing strategy built around cost, reimbursement and peer pricing data.

To help you create a new pricing model, HFRI will conduct the following steps:

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WAYS TO ACCELERATE YOUR FINANCIAL PERFORMANCE

1. Current transaction data review: HFRI will first review your current transaction data across all revenue streams to develop a comprehensive market position summary. Detailed pricing information is documented in the following areas: - Room rates and observation - Emergency department/clinic visits - Diagnostic/therapeutic procedures - Technical anesthesia room - Operating room - Recovery/post-anesthesia care unit (PACU) - Pharmacy - Medical supplies 2. Medicare SAF data review: Once we?ve quantified your pricing, HFRI analysts will review the most recent Inpatient and Outpatient Standard Analytic File (SAF) data provided by the Centers for Medicare and Medicaid Services (CMS).

This information, updated quarterly, gives us access to rates charged for equivalent services by each member of your designated provider peer group. Peer groups can be defined based on any criteria you select: Geographically, by facility size or type, or by those hospitals that are most consistently winning patients from your primary demographic or catchment area due to aggressive pricing.

3. Accurate price comparisons: From these comparisons, you?ll be able to see exactly how your pricing lines up with specific facilities and also the averages for the entire group. By quantifying in percentage terms the extent to which you?re below the average for a specific product or service, you?re able to quickly identify opportunities for increasing prices while remaining within group norms. Conversely, we will also help you flag any instances in which your organization is the high-priced outlier.

4. Specific pricing targets established: Armed with this data, HFRI pricing experts work alongside your financial management team to establish specific pricing targets and timelines based on the opportunities presented. These calculations will also take into account contractual reimbursement rates to ensure you?re not creating excessive contractual write-offs to claims. In addition, we will help you develop effective strategies for areas or services that require pricing sensitivity. For example, you may want to keep prices at, near or even below cost for some services to remain competitive with independent, free-standing facilities. Similarly, areas that may consistently produce negative patient satisfaction results are given special consideration.

5. Transparency and defensible pricing: Importantly, the pricing developed through HFRI?s rational pricing model is defensible based on its relationship to peer organization pricing and therefore is consistent with the requirements of an effective consumer-facing transparency strategy.

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WAYS TO ACCELERATE YOUR FINANCIAL PERFORMANCE

A key element of our pricing suite that can enhance the utility of pricing transparency is a proprietary application that allows staff to tap the pricing matrix to quickly calculate a patient?s financial obligation before a procedure is performed. This functionality is simple to use and not only strengthens patient satisfaction, but also allows staff to improve upfront collections and develop workable payment plans to reduce bad debt.

The net result of this effort is improved profitability through the creation of a detailed and empirically based pricing model. This approach ensures you?re aligned with peer group averages while simultaneously positioned to capitalize on opportunities for maximizing returns on below-market-priced items and services. Working with you, HFRI will revisit your pricing model on a regular basis to allow for course corrections and adjustments based on changing internal or external circumstances.

REVENUE INTEGRITY Rational pricing is essential for cost transparency, competitive positioning and optimal margins. But without a similarly refined approach to revenue cycle management, pricing alone cannot ensure that an organization?s financial foundation is sound. In fact, chronic, often-hidden problems throughout the revenue cycle can not only sabotage financial projections, but may also put the facility at significant compliance risk.

HFRI?s revenue integrity program is a comprehensive service that complements our pricing suite of services by helping ensure critical elements of the revenue cycle ? coding, charge capture and claims management ? are executed correctly and consistently. The main components of the program are: 1. Chargemaster review: We begin with a review of the hospital chargemaster to identify a variety of potential coding issues.

These can include typographical errors, incorrect code assignments, invalid, out-of-date codes or missing codes. Because chargemaster codes are accessed by clinicians throughout the hospital when claims are assembled, undetected errors are often replicated across many claims. The result can either be a significant amount of money left on the table due to under-coding, or an increased compliance risk because of over-coding.

2. Onsite audits: In addition to a documented chargemaster review, HFRI also performs department-specific onsite audits.

Our revenue cycle consultant will meet with leaders from each revenue-generating department to review the department chargemaster and answer coding and charging questions.

By accessing utilization data and recent claims, we?re in a position to spot opportunities for increased reimbursement, improved charge accuracy, more effective compliance and denial reductions.

Additionally, we will flag questionable charge practices based on industry norms. The department audit findings are documented in a written report and submitted to the client with specific recommendations for each department.

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WAYS TO ACCELERATE YOUR FINANCIAL PERFORMANCE

3. Retrospective claims analysis: A third element in HFRI?s revenue integrity program involves a retrospective claims analysis. A qualified coder will carefully examine 100 claims for coding accuracy, including HCPCS, modifiers and ICD-10 codes, by comparing the claim against the supporting documentation. The review is documented on a line-by-line basis and the results presented both in writing and through an internet meeting with the client.

While outpatient reviews typically are most popular, HFRI also conducts inpatient claim reviews. The mix of claims to be audited can be selected by the client or chosen by HFRI, according the client?s preference.

4. Data editor software application: The final component in the HFRI revenue integrity program is the utilization of our software, the PARA Data Editor (PDE). The PDE provides an automated claim audit tool to identify charge capture problems, such as observation cases billed without evaluation and management (E&M) codes or chemotherapy administration charges that don?t include chemotherapy drugs on the same claim. Both client users and HFRI staff rely on the PDE to consistently identify opportunities for improving charge capture and accuracy.

AR RECOVERY AND RESOLUTION HFRI?s scalable, client-specific accounts receivable resolution and recovery solutions allow hospitals to systematically address problem claims across the full AR spectrum. Issues can involve government and commercial payers, as well as managed care, worker?s compensation and personal injury claims.

Through our proprietary, intelligent automation and powerful process engineering, we?re able to resolve all claims, regardless of size or age. That means you?re able to recover collections from insurance claims that otherwise would have been written off.

Read the full white paper and learn more about partnership opportunities with HFRI Financial Resources and PARA Healt h Car e An alyt ics by clicking on the booklet icon to the left.

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PARA Weekly eJournal: October 23, 2019

CALIFORNIA DOH LAB PAYMENT REPORTING REQUIREMENTS

Hundreds of California hospitals are struggling with a requirement to report payment data on laboratory services for all of 2018 to the California State Department of Health Care Services (DHCS). DHCS mailed letters in February reminding hospitals of their obligation to report 2018 payment data on lab services by June 30, 2019 (see a copy on the last page of this document).

Failure to report the data can result in suspension from participation in the Medi-Cal program. This obligation poses a very tough problem for hospitals which do not ?line item post? remittances for lab services.

PARA can help. Please contact your Account Executive for a proposal to mine data from the hospital?s electronic claim file, remittance files, or transaction files which may substantially advance the hospital?s compliance with the data submission requirement.

DHCS has posted a list of the NPIs of organizations that are required to report payment data by CPTÂŽ for all bill types. There is also a list of the laboratory CPTÂŽs which must be reported. https://www.dhcs.ca.gov/provgovpart/Pages/CLLS.aspx

Links and excerpts from the State regulations which impose this requirement are provided below: http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201120120AB1494

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CALIFORNIA DOH LAB PAYMENT REPORTING REQUIREMENTS

Assembly Bill No. 1494 CHAPTER 28 SEC. 9.

Section 14105.22 of the Welfare and Institutions Code, as added by Section 64 of Chapter 230 of the Statutes of 2003, is amended to read: 14105.22. (a) (1) Reimbursement for clinical laboratory or laboratory services, as defined in Section 51137.2 of Title 22 of the California Code of Regulations, may not exceed 80 percent of the lowest maximum allowance established by the federal Medicare Program for the same or similar services.

(2) This subdivision shall be implemented only until the new rate methodology under subdivision (b) is approved by the federal Centers for Medicare and Medicaid Services (CMS). (b) (1) It is the intent of the Legislature that the department develop reimbursement rates for clinical laboratory or laboratory services that are comparable to the payment amounts received from other payers for clinical laboratory or laboratory services. Development of these rates will enable the department to reimburse clinical laboratory or laboratory service providers in compliance with state and federal law.

(2) (A) The provisions of Section 51501(a) of Title 22 of the California Code of Regulations shall not apply to laboratory providers reimbursed under the new rate methodology developed for clinical laboratories or laboratory services pursuant to this subdivision.

(B) In addition to subparagraph (A), laboratory providers reimbursed under any payment reductions implemented pursuant to this section shall not be subject to the provisions of Section 51501(a) of Title 22 of the California Code of Regulations for 12 months following the date of implementation of this reduction.

(3) Reimbursement to providers for clinical laboratory or laboratory services shall not exceed the lowest of the following: (A) The amount billed.

(B) The charge to the general public.

(C) Eighty percent of the lowest maximum allowance established by the federal Medicare Program for the same or similar services.

(D) A reimbursement rate based on an average of the lowest amount that other payers and other state Medicaid programs are paying for similar clinical laboratory or laboratory services. http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201320140AB1124 Assembly Bill No. 1124, CHAPTER 8 (3) Reimbursement to providers for clinical laboratory or laboratory services shall not exceed the lowest of the following: (A) The amount billed (B) The charge to the general public (C) Eighty percent of the lowest maximum allowance established by the federal Medicare Program for the same or similar services (D) A reimbursement rate based on an average of the lowest amount that other payers and other state Medicaid programs are paying for similar clinical laboratory or laboratory services 19

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CALIFORNIA DOH LAB PAYMENT REPORTING REQUIREMENTS

A(4) (A) In addition to the payment reductions implemented pursuant to Section 14105.192, payments shall be reduced by up to 10 percent for clinical laboratory or laboratory services, as defined in Section 51137.2 of Title 22 of the California Code of Regulations, for dates of service on and after July 1, 2012. The payment reductions pursuant to this paragraph shall continue until the new rate methodology under this subdivision has been approved by CMS. (B) Notwithstanding subparagraph (A), the Family Planning, Access, Care, and Treatment (Family PACT) Program pursuant to subdivision (aa) of Section 14132 shall be exempt from the payment reduction specified in this section.

(5) (A) For purposes of establishing reimbursement rates for clinical laboratory or laboratory services based on the lowest amounts other payers are paying providers for similar clinical laboratory or laboratory services, laboratory service providers shall submit data reports within 11 months of the date the act that added this paragraph becomes effective and annually thereafter.

The data initially provided shall be for the 2011 calendar year, and for each subsequent year, shall be based on the previous calendar year and shall specify the provider?s lowest amounts other payers are paying, including other state Medicaid programs and private insurance, minus discounts and rebates. The specific data required for submission under this subparagraph and the format for the data submission shall be determined and specified by the department after receiving stakeholder input pursuant to paragraph (7). (B) The data submitted pursuant to subparagraph (A) may be used to determine reimbursement rates by procedure code based on an average of the lowest amount other payers are paying providers for similar clinical laboratory or laboratory services, excluding significant deviations of cost or volume factors and with consideration to geographical areas. The department shall have the discretion to determine the specific methodology and factors used in the development of the lowest average amount under this subparagraph to ensure compliance with federal Medicaid law and regulations as specified in paragraph (10).

(C) For purposes of subparagraph (B), the department may contract with a vendor for the purposes of collecting payment data reports from clinical laboratories, analyzing payment information, and calculating a proposed rate.

(D) The proposed rates calculated by the vendor described in subparagraph (C) may be used in determining the lowest reimbursement rate for clinical laboratories or laboratory services in accordance with paragraph (3).

(E) Data reports submitted to the department shall be certified by the provider?s certified financial officer or an authorized individual.

(F) Clinical laboratory providers that fail to submit data reports within 30 working days from the time requested by the department shall be subject to the suspension provisions of subdivisions (a) and (c) of Section 14123.

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http://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode=WIC&division=9.&title =&part=3.&chapter=7.&article=3 Welfare and Institutions Code WIC DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.8] ( Division 9 added by Stats. 1965, Ch. 1784. ) PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) CHAPTER 7. Basic Health Care [14000 - 14199.56] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ARTICLE 3. Administration [14100 - 14124.14] ( Article 3 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) 14123.

Participation in the Medi-Cal program by a provider of service is subject to suspension in order to protect the health of the recipients and the funds appropriated to carry out this chapter. (a) (1) The director may suspend a provider of service from further participation under the Medi-Cal program for violation of any provision of this chapter or Chapter 8 (commencing with Section 14200) or any rule or regulation promulgated by the director pursuant to those chapters.

The suspension may be for an indefinite or specified period of time and with or without conditions, or may be imposed with the operation of the suspension stayed or probation granted. The director shall suspend a provider of service for conviction of any felony or any misdemeanor involving fraud, abuse of the Medi-Cal program or any patient, or otherwise substantially related to the qualifications, functions, or duties of a provider of service.

(2) If the provider of service is a clinic, group, corporation, or other association, conviction of any officer, director, or shareholder with a 10 percent or greater interest in that organization, of a crime described in paragraph (1) shall result in the suspension of that organization and the individual convicted if the director believes that suspension would be in the best interest of the Medi-Cal program. If the provider of service is a political subdivision of the state or other government agency, the conviction of the person in charge of the facility of a crime described in paragraph (1) may result in the suspension of that facility. The record of conviction or a certified copy thereof, certified by the clerk of the court or by the judge in whose court the conviction is had, shall be conclusive evidence of the fact that the conviction occurred. A plea or verdict of guilty, or a conviction following a plea of nolo contendere is deemed to be a conviction within the meaning of this section.

(3) After conviction, but before the time for appeal has elapsed or the judgment of conviction has been affirmed on appeal, the director, if he or she believes that suspension would be in the best interests of the Medi-Cal program, may order the suspension of a provider of service. When the time for appeal has elapsed, or the judgment of conviction has been affirmed on appeal or when an order granting probation is made suspending the imposition of sentence irrespective of any subsequent order under Section 1203.4 of the Penal Code allowing a person to withdraw his or her plea of guilty and to enter a plea of not guilty, or setting aside the verdict of guilty, or dismissing the accusation, information, or indictment, the director shall order the suspension of a provider of service.

The suspension shall not take effect earlier than the date of the director?s order. Suspension following a conviction is not subject to the proceedings required in subdivision (c). However, the director may grant an informal hearing at the request of the provider of service to determine in the director?s sole discretion if the circumstances surrounding the conviction justify rescinding or otherwise modifying the suspension provided for in this subdivision.

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CALIFORNIA DOH LAB PAYMENT REPORTING REQUIREMENTS

(4) If the provider of service appeals the conviction and the conviction is reversed, the provider may apply for reinstatement to the Medi-Cal program after the conviction is reversed.

Notwithstanding Section 14124.6, the application for reinstatement shall not be subject to the one-year waiting period for the filing of a reinstatement petition pursuant to Section 11522 of the Government Code. (b) Whenever the director receives written notification from the Secretary of the United States Department of Health and Human Services that a physician or other individual practitioner has been suspended from participation in the Medicare or Medicaid programs, the director shall promptly suspend the practitioner from participation in the Medi-Cal program and notify the Administrative Director of the Division of Workers?Compensation of the suspension, in accordance with paragraph (2) of subdivision (e). This automatic suspension is not subject to the proceedings required in subdivision (c). No payment from state or federal funds may be made for any item or service rendered by the practitioner during the period of suspension. (c) The proceedings for suspension shall be conducted pursuant to Section 100171 of the Health and Safety Code. The director may temporarily suspend any provider of service prior to any hearing when in his or her opinion that action is necessary to protect the public welfare or the interests of the Medi-Cal program. The director shall notify the provider of service of the temporary suspension and the effective date thereof and at the same time serve the provider with an accusation. The accusation and all proceedings thereafter shall be in accordance with Section 100171 of the Health and Safety Code. Upon receipt of a notice of defense by the provider, the director shall set the matter for hearing within 30 days after receipt of the notice. The temporary suspension shall remain in effect until such time as the hearing is completed and the director has made a final determination on the merits. The temporary suspension shall, however, be deemed vacated if the director fails to make a final determination on the merits within 60 days after the original hearing has been completed. This subdivision does not apply where the suspension of a provider is based upon the conviction of any crime involving fraud, abuse of the Medi-Cal program, or suspension from the federal Medicare program. In those instances, suspension shall be automatic. (d) (1) The suspension by the director of any provider of service shall preclude the provider from submitting claims for payment, either personally or through claims submitted by any clinic, group, corporation, or other association to the Medi-Cal program for any services or supplies the provider has provided under the program, except for services or supplies provided prior to the suspension.

No clinic, group, corporation, or other association which is a provider of service shall submit claims for payment to the Medi-Cal program for any services or supplies provided by a person within the organization who has been suspended or revoked by the director, except for services or supplies provided prior to the suspension.

(2) If the provisions of this chapter, Chapter 8 (commencing with Section 14200), or the regulations promulgated by the director are violated by a provider of service that is a clinic, group, corporation, or other association, the director may suspend the organization and any individual person within the organization who is responsible for the violation.

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CALIFORNIA DOH LAB PAYMENT REPORTING REQUIREMENTS

(e) (1) Notice of the suspension shall be sent by the director to the provider?s state licensing, certifying, or registering authority, along with the evidence upon which the suspension was based.

(2) At the same time notice is provided pursuant to paragraph (1), the director shall provide written notification of the suspension to the Administrative Director of the Division of Workers?

Compensation, for purposes of Section 139.21 of the Labor Code. (f) In addition to the bases for suspension contained in subdivisions (a) and (b), the director may suspend a provider of service from further participation under the Medi-Cal dental program for the provision of services that are below or less than the standard of acceptable quality, as established by the California Dental Association Guidelines for the Assessment of Clinical Quality and Professional Performance, Copyright 1995, Third Edition, as periodically amended. The suspension shall be subject to the requirements contained in subdivisions (a) to (e), inclusive.

(Amended by Stats. 2016, Ch. 852, Sec. 3. (AB 1244) Effective January 1, 2017.)

A copy of a DHCS letter received by one hospital is provided here.

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PARA Weekly eJournal: October 23, 2019

MODIFIER REQUIREMENT FOR SERVICES FROM THERAPY ASSISTANTS CMS will require providers to identify therapy services furnished by a Physical Therapy Assistant (PTA) or Occupational Therapy Assistant (OTA) by use of the CQ and CO modifiers effective 1/ 1/ 2020 .

Section 1834 (v)(2)(B) of the Bipartisan Budget Act of 2018 requires that claims submitted on or after January 1, 2020 for outpatient physical therapy or occupational therapy must include the modifiers established by CMS to identify that services were rendered in whole or in part by a PTA or an OTA. These modifiers will be for reporting and data collection only; payment will not be affected in 2020.

Beginning January 1, 2022 providers will receive payment at 85% of the of the otherwise applicable Medicare Part B payment for services provided by a PTA or OTA. Beginning January 1, 2020 providers will be required to report Modifiers CO and CQ to identify services furnished by a PTA or an OTA respectively. The use of the CO and CQ modifiers and the subsequent 2022 payment reduction apply to all hospital outpatient departments, SNFs, CORFs, Home Health and Rehabilitation Agencies. Critical Access Hospitals are exempt from these requirements because they are not paid under PFS rates for therapy services.

When therapy services are rendered by a PTA or an OTA, the CO and CQ modifiers will be used instead of the existing GP and GO modifiers that are currently used to identify physical and occupational therapy services. The GP and GO modifiers will continue to be used to identify services provided by a physical or occupational therapist.

The 2020 MPFS proposed rule sets a 10 percent minimum standard for when the CO and CQ modifiers will apply. If a PTA or OTA provides more than 10 percent of the care in a treatment session, then the provider would report the services rendered with the CO and CQ modifiers.

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MODIFIER REQUIREMENT FOR SERVICES FROM THERAPY ASSISTANTS

A link to the fact sheet on the 2020 MPFS Proposed Rule, which includes this requirement: https://www.cms.gov/newsroom/fact-sheets/proposed -policy-payment-and-quality-provisions-changesmedicare-physician-fee-schedule-calendar-year-2 The proposed rule provides clarification on how to calculate the 10 percent limit. There are two possible methods that can be used for calculation: Method 1: Divide the number of minutes of care provided by the PTA/OTA by the total minutes of care provided then multiply by 100. That will give providers the percentage of time of care provided by the PTA/OTA. Providers should round the number to the nearest whole number.

Anything equal to or greater than 11 percent requires application of the modifier.

Method 2: Divide the total time of care provided to the patient by 10 (round to the nearest whole number) and add 1 minute to set the minimum time requirement. If the treatment total time was 60 minutes, then 10% is 6 minutes plus 1 minute is 7 minutes. If the PTA/OTA care was 7 minutes or more then the CO/CQ modifier would be added to those line items.

The following chart is provided in the proposed rule for the Method 2 calculation:

Also, it is important to note that there is a proposed documentation requirement included in the MPFS proposed rule. This proposed requirement provides a short description of the application or non-application of the CO/CQ modifiers.

Since modifiers are applied on a per code basis, documentation would need to state the code, modifier applied or not applied, and the amount of time services were provided by the PTA/OTA to justify appending or omitting the CO/CQ modifiers.

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PARA Weekly eJournal: October 23, 2019

2020 CODING UPDATE DOCUMENTS AVAILABLE

In preparation for the year-end CPT®/HCPCS update, PARA has prepared eleven brief ?2020 Coding Update? documents listing deleted codes and added codes within a particular clinical area or procedure group. The documents are available on the PARA Data Editor ?Advisor? tab.

The coding topics addressed do not encompass all CPT® updates, only those which are most likely to be ?hard-coded? to a line item in a facility chargemaster. Topics are divided into immediately related areas, and more than one paper may contain information useful to a service line manager.

Due to CPT® licensing restrictions, these documents cannot be published within the PARA Weekly Update. PARA Data Editor users may access the information on the Advisor tab; search ?Coding Update? in the type field, and/or 2020 in the subject field, as illustrated below:

Medicare coverage information is not available on all of the new codes at this time. Following the release of the OPPS Final Rule in November, coding update papers will be revised to indicate whether Medicare will accept/cover the new codes that are not clear.

PARA Data Editor users can identify updated papers by the word ?Revised? in the title and the date issued will be updated.

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PARA Weekly eJournal: October 23, 2019

WEEKLY IT UPDATE

PARA HealthCare Analytics has provided a list of enhancements and updates that our Information Technology (IT) team has made to the PARA Data Editor this past week.

The following tables includes which version of the PDE was updated, the location within the PDE, and a description of the enhancement.

Week ly IT Updat e

T his Week 's Updates

Prev ious Updates

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PARA Weekly eJournal: October 23, 2019

PAMA PRIVATE PAYER LAB PAYMENT RATE REPORTING

In the 2019 OPPS Final Rule Medicare added a new reporting requirement to hospital ?outreach? laboratories which submit claims for non-patient services, i.e. blood sample processing without patient contact, on the ?non-patient services? 14X type of bill (TOB.) In early 2020, hospitals will be required to report private payor payment rates for the same tests that Medicare reimburses on the clinical laboratory fee schedule if they received greater than $12,500 in Medicare revenues/reimbursement for claims billed on the 141 TOB for dates of service between January 1, 2019 and June 30, 2019.

CMS will collect private-payer data from hospitals for January through June of 2019, and use it to develop the overall weighted median payment rate for each test under the Clinical Laboratory Fee Schedule (CLFS). The weighted median will then serve as the basis of reimbursement for three years beginning in 2021.

Medicare clarified reporting requirements in an MLN article published in late February, 2019: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/Downloads/SE19006.pdf

Hospitals conducting ?outreach? laboratory service should verify whether the 141 bill type was used to report ?non-patient services? for lab testing. Regardless if the outreach lab services are reported under the same NPI as the hospital, the hospital must evaluate whether it meets two other tests, and report private payer data if it meets the tests for an ?applicable laboratory.?

Hospitals with labs billing on the 141 TOB are required to report payment data if: - the hospital receives more than $12,500 in Medicare revenue/reimbursement for non-patient clinical lab services reported on bill type 141 in the period January 1 through June 30 2019, and - the majority of revenue/reimbursements received from Medicare for services billed on the 141 bill type were paid under the Clinical Lab Fee Schedule (this is highly likely for TOB 141 claims.)

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PAMA PRIVATE PAYER LAB PAYMENT RATE REPORTING

If a hospital is required to report, private payer data must be collected for the period 1/1/19 through 6/30/19, analyzed, validated, and reported to Medicare in the next reporting period, 1/1/20 through 3/31/20. The window for reporting this data to Medicare is after January 1, 2020, but no later than March 31, 2020. Significant penalties (of $10,017 per violation per day) may apply if reporting is not complete, accurate, and timely. There is no exception for Critical Access Hospitals.

Since the vast majority of services billable on the 141 type of bill are paid under the Clinical Lab Fee Schedule, the central question is whether the hospital received $12,500 in reimbursement from Medicare (not including managed Medicare) during the data collection period January through June 2019 for non-patient lab testing.

PARA clients can reasonably assess whether the $12,500 threshold was met by contacting their PARA Account Executive. PARA purchases Medicare outpatient claims data for prior periods, and this data includes payments made on the 14X type of bill by Medicare. We have 2018 and Q1 2019, Q2 will be available soon.

If the sum of payments on 141 TOB indicate that the hospital has met or exceeded the $12,500 threshold in the period January through June, 2019, then the hospital should prepare to report data for the January-June 2019 data collection period.

PARA offers assistance with generating the data required for reporting private payer rates. The PARA Data Editor offers the ability to analyze electronic remittance files to quickly generate a spreadsheet of the allowable rate paid by CPTÂŽ codes on 141 bill types. This data will be configured into the required format for Medicare reporting.

Clients will likely have some payments that will require manual research if not paid on a submitted 835 file, since PARA cannot research payments submitted on paper remittances.

To learn more about PARA?s Lab Payment Reporting Analytical Services, please contact your PARA account executive (Sandra LaPlace at slaplace@para-hcfs.com, or Violet Archuleta-Chiu at varchuleta@para-hcfs.com.)

A link and an excerpt from the Medicare MLN Matters publication on this topic is provided below: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/ Downloads/SE19006.pdf

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PAMA PRIVATE PAYER LAB PAYMENT RATE REPORTING

Additionally, Medicare updated an FAQ document on September 9, 2019 at the following link: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/ Downloads/CY2019-CLFS-FAQs.pdf

Finally, excerpts from the 2019 Clinical Lab Fee Schedule Final Rule regarding penalties and certification are provided below: https://www.govinfo.gov/content/pkg/FR-2016-06-23/pdf/2016-14531.pdf Federal Register / Vol. 81, No. 121 / Thursday, June 23, 2016 / Rules and Regulations; page 41038 ?? We proposed to apply a civil monetary penalty (CMP) to an applicable laboratory that fails to report or that makes a misrepresentation or omission in reporting applicable information. We proposed to require all data to be certified by the President, Chief Executive Officer (CEO), or Chief Financial Officer (CFO) of an applicable laboratory before it is submitted to CMS. As required by section 1834A(a)(10) of the Act, certain information disclosed by a laboratory under section 1834A(a) of the Act is confidential and may not be disclosed by the Secretary or a Medicare contractor in a form that reveals the identity of a specific payor or laboratory, or prices, charges or payments made to any such laboratory, with several exceptions. We are revising the certification and CMP policies in the final rule to require that the accuracy of the data be certified by the President, CEO, or CFO of the reporting entity, or an individual who has been delegated to sign for, and who reports directly to such an officer. Similarly, the reporting entity will be subject to CMPs for the failure to report or the misrepresentation or omission in reporting applicable information. Additionally, we are updating the CMP amount to reflect changes required by the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015 (Sec. 701 of the Bipartisan Budget Act of 2015, Pub. L. 114?74, November 2, 2015).

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Comment: Several commenters commented on the proposed CMPs of up to $10,000 per day per violation and said the amount should be reconsidered, particularly for community laboratories that cannot afford such penalties. The commenters also suggested that CMS only apply penalties in cases where there is evidence that a laboratory intentionally provided inaccurate or mistaken information.

Response: The statute authorizes CMPs of up to $10,000 per day per violation. However, in situations where our review reveals that the data submitted is incomplete or incorrect, we will work with the OIG to assess whether a CMP should be applied, and if so, the appropriate amount based on the specific circumstances. Although the statute authorizes CMPs of up to $10,000 per day per violation, we recognize that this is the maximum statutory amount, and not a minimum. The actual penalty imposed will be determined based on the facts and circumstances of each violation.

We note that this amount was recently amended by the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015 (Sec. 701 of the Bipartisan Budget Act of 2015, Public Law 114?74, November 2, 2015) (the 2015 Act), which amends the Federal Civil Penalties Inflation Adjustment Act of 1990 (the Inflation Adjustment Act) (Pub. L. 101?410, 104 Stat. 890 (1990) (codified as amended at 28 U.S.C. 2461 note 2(a)). The Inflation Adjustment Act required all agencies, including HHS, to adjust any CMPs within their jurisdiction by increasing the maximum CMP or the range of minimum and maximum CMPs, as applicable, for each CMP by the cost-of-living adjustment.

The 2015 Act was enacted to improve the effectiveness of civil monetary penalties and to maintain their deterrent effect. Among other things, it revises the method of calculating inflation adjustments so that, instead of the significant rounding methodology applied under the Inflation Adjustment Act, penalty amounts are now simply rounded to the nearest $1.

Accordingly, in applying the requirements of the Inflation Adjustment Act, as amended, to the penalty amounts specified in section 1834A(a)(9) of the Act, the Secretary may assess CMPs of up to $10,017 per day per violation beginning on the effective date of this rule. We have revised ยง 414.504(e) to reflect this statutory adjustment.

The 2015 Act also requires agencies to publish annual adjustments not later than January 15 of every year after publication of the initial adjustment. Therefore, subsequent to this initial adjustment, CMP adjustments applicable to section 1834A of the Act will be updated annually through regulations published by the Secretary no later than January 15 of every year.

Comment: Several commenters requested clarification as to what constitutes an error that warrants a penalty, and stated that CMS should not apply any penalties or sanctions for reporting errors until an appeals process is outlined. Some commenters stated that CMS indicated in the proposed rule that full implementation of the new CLFS regulations will take between 5 and 6 years, and suggested that no penalties be assessed during this time.

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Response: As previously mentioned, following the publication of this final rule, we will issue additional guidance on the assessment of CMPs, including what would constitute a failure to report or a misrepresentation or omission in reporting.

We also note that we do not intend to assess CMPs for minor errors.

The actual penalty imposed will be determined based on the facts and circumstances of each violation.

While full implementation of the new CLFS regulations will take several years, it is critical that reporting entities provide accurate and complete information at the outset so that accurate prices can be set, and while we do not expect that CMPs will be assessed frequently, we believe the ability to assess CMPs on reporting entities when appropriate is consistent with our statutory authority.

Section 1834A(a)(9)(B) of the Act further provides that the provisions of section 1128A of the Act (other than sections (a) and (b)) shall apply to a CMP under this paragraph in the same manner as they apply to a CMP or proceeding under section 1128A(a) of the Act. Comment: A commenter stated that the economics and other characteristics of the laboratory industry differ greatly from the pharmaceutical industry making the comparison to Part B drugs inapplicable.

Response: We agree there are important differences between the pharmaceutical industry and the laboratory industry, but believe the general approach taken for the application of CMPs for violations in reporting drug prices is an appropriate model to consider when we develop guidance on the application of CMPs for violations in reporting of applicable information.

Comment: A commenter stated that CMPs can be an effective tool for encouraging data reporting and ensuring compliance with the PAMA reporting obligations but that there will be significant confusion within the laboratory community initially.

The commenter requested that CMS not impose CMPs during the initial cycle on any laboratory that has shown a good faith effort to comply with the reporting requirements, and that CMS should notify applicable laboratories of their reporting obligations to ensure compliant reporting and to reduce the likelihood of penalties.

Response: We appreciate the commenter?s understanding of the important role of CMPs in ensuring accurate and complete data reporting and acknowledge the commenter?s concerns regarding the provision of data during the initial reporting period. We are uncertain as to what the commenter means by ??any laboratory that has shown a good faith effort to comply with the reporting requirements??As we have noted previously, we do not intend to assess CMPs for minor errors, and will provide additional information in subregulatory guidance to facilitate compliant reporting and to reduce the likelihood of penalties.

Additionally, we are clarifying in ยง 414.504(e) that the CMPs will be assessed at the reporting entity level, not at the applicable laboratory level, to ensure consistency with the data reporting and certification 32

PARA Weekly eJournal: October 23, 2019

PAMA PRIVATE PAYER LAB PAYMENT RATE REPORTING

Comment: Some commenters stated that smaller laboratories without sufficient administrative staff face challenges in reporting as compared to larger, well-resourced laboratories. These commenters suggested that the size of the penalty should correspond to the size of the laboratory, so that laboratories with limited resources would not be forced to close as a result of such penalties.

Response: We will consider all relevant information when determining the amount of a CMP, and we will work with the OIG to ensure that any penalties assessed are fairly applied. The purpose of PAMA is to collect complete and accurate data in order to set payment rates, not to force a laboratory to close as a result of a CMP assessment.

Comment: Some commenters were concerned that the period to understand and comply with the data requirements is too short and could compromise the integrity of the data submitted.

Response: In section II.D of this final rule, we discuss our final data collection and reporting process, which is changed from our proposal in the proposed rule.

Under the process we are adopting in this final rule, applicable laboratories will have a 6-month data collection period, followed by a 6-month period between the end of the data collection period and the beginning of the data reporting period to allow applicable laboratories time to ensure the accuracy of their data, followed by a 3-month data reporting period during which reporting entities will report applicable information to us.

We believe this process will provide applicable laboratories adequate time to understand and prepare for the submission of the required data.

Comment: Some commenters noted that accidental errors are inevitable with a new, first-of-its-kind, untested laboratory price reporting system, and the associated fines are significant. These commenters also opined that the new reporting requirements will require significant changes for the clinical laboratory community to undertake with no funding provided to make those changes, and that implementation of this law is being fast-tracked, which will lead to mistakes and unexpected problems.

Response: As discussed in section II.D.3 of this final rule, we are moving the implementation date of section 1834A of the Act to January 1, 2018. We expect applicable laboratories will have sufficient time to review their data for accuracy and completeness during the 6-month time period we are affording between the end of the data collection period and the beginning of the data reporting period. We recognize that there is a cost associated with the development and submission of data under section 1834A of the Act, but we believe this data submission process is an essential mechanism to establish fair and accurate Medicare payment rates for CDLTs. We are proceeding with implementation of the new reporting requirements in accordance with the statutory requirements, notwithstanding the new implementation date of January 1, 2018.

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PARA Weekly eJournal: October 23, 2019

PAMA PRIVATE PAYER LAB PAYMENT RATE REPORTING

2. Data Certification Section 1834A(a)(7) of the Act requires that an officer of each laboratory must certify the accuracy and completeness of the reported information required by section 1834A(a) of the Act. We proposed to implement this provision by requiring in ยง 414.504(d) that the President, CEO, or CFO of an applicable laboratory or an individual who has been delegated authority to sign for, and who reports directly to, the laboratory?s President, CEO, or CFO, must sign a certification statement and be responsible for assuring that the applicable information provided is accurate, complete, and truthful, and meets all the reporting parameters. We stated that we would specify the processes for certification in subregulatory guidance prior to January 1, 2016.

A discussion of the comments we received on this topic, and our responses to those comments, appears below.

Comment: A few commenters objected to our plan to specify the processes for certification in subregulatory guidance prior to January 1, 2016, stating that some of these process issues need to be resolved in the final rule before subregulatory guidance is issued. Others have asked that the subregulatory guidance be issued as soon as possible.

Response: We will issue subregulatory guidance specifying the certification process for the submission of applicable information following publication of this final rule.

As discussed in section II.D.3 of this final rule, we are moving the implementation date of the revised CLFS to January 1, 2018, so we now expect to issue the subregulatory guidance prior to January 1, 2018.

Comment: Some commenters requested that CMS create a certification form for applicable laboratories that states that the information and statements submitted are accurate and complete to the best of the laboratory?s knowledge and the submission is made in good faith.

Response: We appreciate the commenters?suggestion and will take it into consideration as we develop subregulatory guidance for the certification process following the publication of this final rule.

Comment: Some commenters stated that most laboratory Presidents, CEOs, and CFOs are not personally familiar with the volume and private payor rates for each laboratory test their labs offer, and they should not be required to certify the accuracy of the data submitted. The commenter suggested that a laboratory officer should be responsible for certifying that the data submitted is accurate to the best of his or her knowledge.

Response: We agree with the commenter and in accordance with the changes to the data reporting requirements in this final rule, we have revised ยง 414.504(d) to require the President, CEO, or CFO of the reporting entity or an individual who has been delegated authority to sign for, and who reports directly to, such an officer to certify the accuracy of the data submitted for the 34 reporting entity.

PARA Weekly eJournal: October 23, 2019

ACCURATE CODING FOR VACCINES REQUIRES PRECISION

From flu to tetanus, vaccines are among the most common outpatient procedures providers administer on a day-to-day basis.

But they can also be complex to code and bill, and undetected mistakes can result in continual underpayment for services rendered.

What makes vaccines so tricky? In most instances, coders must consider a range of factors to ensure the procedure is properly coded, and it can be easy to overlook specific details or nuances. This is especially true if multiple injections are given to a single patient during one encounter.

Some of the key variables associated with vaccine coding include: - Patient age - Insurance - Route of administration - Total number of vaccines given in the same encounter - Physician counseling - State vaccines programs Q-Codes Vaccine codes are published on a semi-annual basis, typically July 1 and January 1, by the American Medical Association (AMA). CPT速 vaccine codes range from 90476 through 90749. In recent years, Medicare has created additional Q-codes for vaccines. Q-codes are reimbursed at reasonable cost to providers, and Medicare deductible and co-insurance amounts do not apply when the Q-codes are reported to Medicare.

Age-restricted vaccines While many vaccines don?t have specific age requirements, others can be designated pediatric, adolescent or adult. As a result, it?s important for coders to confirm that the vaccine administered is appropriate for the patient?s age.

Code set administration In most vaccine billing scenarios, practices will bill separately for the vaccine and the vaccine administration. Administration codes encompass three general categories: - CPT速 range 90471 ? 90474 identifies vaccines without Counseling (over 18 years of age) - CPT速 range 90460 ? 90461 identifies vaccines with Counseling (thru age 18) - HCPCS Codes G0008, G0009 and G0010 are specific to Medicare beneficiaries State programs Some physician practices participate in state-sponsored Vaccines for Children (VFC) programs. Because the state generally provides the practice with the vaccines, physicians may not charge beneficiaries for the vaccines and physicians are not separately reimbursed by Medicaid or commercial carriers.

However, providers may charge patients for the administration fee associated with providing the vaccine.

For vaccines provided as part of the VFC program, the CPT速 code range is 90476 ? 90749, with modifier SL appended in the first reporting modifier field.

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PARA Weekly eJournal: October 23, 2019

ACCURATE CODING FOR VACCINES REQUIRES PRECISION

Route of administration Ensuring the correct route of administration allows the coder to select the appropriate administration code. Most vaccines are given as injections and are reported using administration codes 90471 and 90472. But there are a few oral and intra-nasal vaccines that are reported using administration codes 90473 and 90474.

Initial vaccines If one or more vaccines are administered during an encounter, it is necessary to specify an initial administration code first. Initial administration codes include: - 90471: Immunization administration for percutaneous, intra-dermal, subcutaneous or intramuscular injections, initial - 90473: Immunization administration for intra-nasal or oral route, initial Only one initial administration code is reported per encounter. If both injectable and oral/intra-nasal vaccines are performed during the same visit, providers should report 90471 as the initial administration code. Codes 90471 ? 90472 have a slightly higher reimbursement than oral/intra-nasal administration.

Subsequent vaccines If more than one vaccine is administered on the same day, a second or third administration code is required to document the additional vaccines. All subsequent vaccine codes (90472 and 90474) are classified as add-on codes and must be reported with an initial administration code. The definitions for subsequent administration codes are: - 90472: Immunization administration for percutaneous, intra-dermal, subcutaneous or intramuscular injections, each additional vaccine - 90474: Immunization administration for intra-nasal or oral route, each additional vaccine When three or more vaccines are performed during an encounter, units should be applied to the administration code for each additional vaccine of the same type (injectable or oral).

Here are some examples: - Five injectable vaccines: report 90471 X1 unit (initial) and 90472 X4 units (subsequent) - One intra-nasal and two oral vaccines: 90473 X1 unit (initial) and 90474 X2 units (subsequent) - Four injectable vaccines and one oral vaccine: 90471 X1 unit (initial) and 90472 X3 units (subsequent) and 90474 X1 unit (subsequent)

Keepin g it all st r aigh t Staying abreast of the latest coding directives can be a challenge, and it can be doubly so when it comes to vaccines, given all the factors that need to be accounted for to code and bill correctly.

That?s why Healthcare Financial Resources Inc. (HFRI) and PARA HealthCare Analytics have partnered to deliver comprehensive revenue cycle services to support accurate coding, clean claims and timely and appropriate reimbursement. Contact us today to learn more about the many ways we can help your organization.

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PARA Weekly eJournal: October 23, 2019

PARA YEAR-END HCPCS UPDATE PROCESS -- NEW UPDATES

As usual, PARA clients will be fully supported with information and assistance on the annual CPT速 HCPCS coding updates.

The PARA Data Editor (PDE) contains a copy of each client chargemaster; we use the powerful features of the PDE to identify any line item in the chargemaster which has a HCPCS code assigned that will be deleted as of January 1, 2020. For this reason, it is important that clients check to ensure that a recent copy of the chargemaster has been supplied to PARA for use in the year-end update.

PARA will produce excel spreadsheets of each CDM line item, as well as our recommendation for alternate codes, in three waves as information is released from the following sources: 1. The American Medical Association?s publication of new, changed, and deleted CPT速 codes; this information is released in September of each year. PARA will produce the first spreadsheet of CPT速 updates for client review in October, 2019.

2. Medicare?s 2019 OPPS Final Rule, typically published the first week of November; PARA will perform analysis and produce the second spreadsheet to include both the CPT速 information previously supplied, as well as alpha-numeric HCPCS updates (J-codes, G-codes, C-codes, etc.) from the Final Rule. Clients may expect this spreadsheet to be available in November, 2019.

3. Medicare?s 2018 Clinical Lab Fee Schedule (CLFS) ? typically published in late November, the CLFS will reveal whether Medicare will accept new CPTs generated by the AMA, or whether Medicare will require another reporting method. The final spreadsheet will be available in December, 2019.

Clients will be notified by email as spreadsheets are produced and recorded on the PARA Data Editor ?Admin? tab, under the ?Docs? subtab. The spreadsheet will appear.

In addition, PARA consultants will publish concise papers on coding update topics in order to ensure that topical information is available in a manner that is organized and easy to understand. PARA clients may rest assured that they will have full support for year-end HCPCS coding updates to the chargemaster.

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PARA Weekly eJournal: October 23, 2019

USE OF KX MODIFIER FOR PART B IMMUNOSUPPRESIVE DRUG CLAIMS

Medicare covers Part B beneficiaries for immunosuppressive drugs when the patient has received an organ transplant paid through Medicare Part A. If the Medicare Common Working File (CWF) cannot locate the claim that paid for the transplant in the patient?s Master Beneficiary Record (MBR), the claim line for the drug will deny.

This could happen in cases where the patient was enrolled in a Medicare Advantage (MA) program. The CWF does not have a record of the transplant unless Medicare paid for the procedure. To ensure payment for claims when a beneficiary is covered, a KX modifier may be used to indicate the beneficiary meets the coverage requirements.

Additional information can be found through CMS through the link below: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ Fast-Facts/Proper-Use-KX-Modifier-for-Part-B-Immunosuppressive-Drug-Claims.html

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PARA Weekly eJournal: October 23, 2019

USE OF KX MODIFIER FOR PART B IMMUNOSUPPRESIVE DRUG CLAIMS

Use of the KX modifier indicates that the supplier of the drug (e.g., pharmacies) attests the patient was eligible for Medicare Part A on the date of the transplant, the immunosuppressive drugs are medically necessary, and the transplant date and eligibility are documented in the patient?s record. Additionally, the date of the transplant must precede the date of service of administration of first immunosuppressive drug.

If the supplier is not able to meet the requirements for using the KX modifier, they cannot bill Medicare for the immunosuppressive drug. The supplier also may not issue the beneficiary an ABN or collect or bill for the drug.

CMS provided additional information after an OIG audit reported that of 75 claims reviewed, 10 did not support the use of the KX modifier. https://oig.hhs.gov/oas/reports/region6/61500018.pdf

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PARA Weekly eJournal: October 23, 2019

MLN CONNECTS PARA invites you to check out the mlnconnects page available from the Centers For Medicare and Medicaid (CMS). It's chock full of news and information, training opportunities, events and more! Each week PARA will bring you the latest news and links to available resources. Click each link for the PDF!

Thursday, October 17, 2019 New s

· New Medicare Card: MBI Transition Ends in Less Than 10 Weeks · Guide for Appropriate Tapering or Discontinuation of Long-Term Opioid Use · ICD-10 Coordination and Maintenance: Deadline for Comments November 8 · CMS Health Equity Award: Submit Nomination by November 15 · Quality Payment Program: Participation Status Tool Includes Second Snapshot of Data · Atherectomy: Comparative Billing Report in October · Protect Your Patients from Influenza this Season Com plian ce

· Cardiac Device Credits: Medicare Billing Even t s

· Submitting Your Medicare Part A Cost Report Electronically Webcast ?

November 5

· Atherectomy: Comparative Billing Report Webinar ? November 6 · Provider Compliance Focus Group Meeting ? November 12 M LN M at t er s® Ar t icles

· Add Dates of Service (DOS) for Pneumococcal Pneumonia Vaccination (PPV) Health Care Procedure Code System (HCPCS) Codes (90670, 90732), and Remove Next Eligible Dates for PPV HCPCS

· Fiscal Year (FY) 2020 Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital (LTCH) PPS Changes

· Home Health Orders for Nurse Practitioners under the Maryland Total Cost of Care (TCOC) Model 40

PARA Weekly eJournal: October 23, 2019

There was ONE new or revised Med Learn (MLN Matters) article released this week.

To go to the full Med Learn document simply click on the screen shot or the link.

FIND ALL THESE MED LEARNS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly eJournal: October 23, 2019

The link to this Med Learn MM11455

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PARA Weekly eJournal: October 23, 2019

There were SIX new or revised Transmittals released this week.

To go to the full Transmittal document simply click on the screen shot or the link.

7

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly eJournal: October 23, 2019

The link to this Transmittal R2374OTN

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PARA Weekly eJournal: October 23, 2019

The link to this Transmittal R2375OTN

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PARA Weekly eJournal: October 23, 2019

The link to this Transmittal R912PI

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PARA Weekly eJournal: October 23, 2019

The link to this Transmittal R328FM

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PARA Weekly eJournal: October 23, 2019

The link to this Transmittal R480PR1

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PARA Weekly eJournal: October 23, 2019

The link to this Transmittal R230DEMO

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PARA Weekly eJournal: October 23, 2019

The link to this Transmittal R2370OTN

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PARA Weekly eJournal: October 23, 2019

Con t act Ou r Team

Peter Ripper

M onica Lelevich

Randi Brantner

President

Director Audit Services

Director Financial Analytics

m lelevich@para-hcfs.com

rbrantner@para-hcfs.com

pripper@para-hcfs.com

Violet Archuleta-Chiu Senior Account Executive

Sandra LaPlace

Steve M aldonado

Account Executive

Director Marketing

slaplace@para-hcfs.com

smaldonado@para-hcfs.com

varchuleta@para-hcfs.com

In t r odu cin g, ou r n ew par t n er .

Nikki Graves

Sonya Sestili

Deann M ay

Senior Revenue Cycle Consultant

Chargemaster Client Manager

h f r Review i.n et Claim Specialist

ngraves@para-hcfs.com

ssestili@para-hcfs.com

dmay@para-hcfs.com

M ary M cDonnell

Patti Lew is

Director, PDE Training & Development

Director Business Operations

mmcdonnell@para-hcfs.com

plewis@para-hcfs.com

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